9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)
12. How does your current condition interfere with your:
13. Review of Systems
Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please select beside any condition that you've Had or currently Have and initial to the right.
None Initials
To set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.Initials I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.InitialsI may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.InitialsI realize that an X-ray examination may be hazardous to an unborn child and I certify that tothe best of my knowledge I am not pregnant. Date of last menstrual period: Date InitialsI grant permission lo be called and texted lo confirm or reschedule an appointment and lo be sent occasional cards, letters, emails or health information lo me as an extension of my care in this office.Initials I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.InitialsTo the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.